Upper urinary tract infection/pyelonephritis

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Required actions: review the last three urine cultures (up to 12 months ago):

  • Has a gentamicin resistant organism been isolated? If Yes, contact microbiology.

Required investigations

  • Blood cultures
  • Urine culture (preferably midstream specimen or catheter specimen if catheterised)

Antibiotic recommendations

Recommended total duration: 7 days (total duration = IV and oral)

Recommended Antibiotic

Gentamicin (use NHS Lothian Calculator located AMT intranet page

Where Enterococcus has been isolated in urine in last 12 months OR source of infection is unclear OR patients has signs of severe sepsis consider adding:

Amoxicillin 1g every 8 hours IV

Penicillin allergy

Gentamicin (use NHS Lothian Calculator located AMT intranet page)

Where Enterococcus has been isolated in urine in last 12 months OR source of infection is unclear OR patients has signs of severe sepsis consider adding:

Vancomycin (use NHS Lothian Calculator located AMT intranet page)

 

48-72 hour review

At 48-72 hours review the need for ongoing antibiotics & review microbiology results

Is the patient improving?

NO, ask for advice.

YES, review questions below:

  • Has an AKI developed whilst in hospital (AKI = x1.5 rise in creatinine from baseline)?
  • Has the patient developed gentamicin toxicity (hearing loss or disturbed balance)?
  • Has the patient grown gentamicin-resistant organisms?

If the answer is "Yes" to any of these questions ask for advice.

If the answer is “No” to all these questions and IV antibiotics are still required, continue gentamicin up to Day 5.

At day 5 review the patient and the antibiotic plan:

  • Is IV to oral switch possible?
  • If not, ask for advice.

Gentamicin is associated with irreversible hearing loss and balance problems; only continue regimens containing gentamicin past 5 days on recommendation from Microbiology/Infectious Diseases.

IV to oral switch

REVIEW MICROBIOLOGY RESULTS

  • Where a urine or blood culture result is positive choose an antibiotic to which the isolate is sensitive preferentially from the Access group of antibiotics (e.g. amoxicillin or cotrimoxazole).
  • Nitrofurantoin is not suitable for IV oral step down for systemic infections. Pivmecillinam, and cefalexin should only be used for IVOST after discussion with an infection specialist.

If no positive microbiology results available:

Recommended treatment

Including for penicillin allergic

Co-trimoxazole 960mg every 12 hours orally

Not suitable if patient allergic to trimethoprim, or urine cultures in previous 12 months have shown a trimethoprim-resistant organism.
Alternative for people with a lower-risk of C.difficile

Co-amoxiclav 625mg every 8 hours orally

Avoid in people >65yrs, or who have had previous C.diff infection. 
Where the above guidance is not suitable including where a more resistant isolate has been identified then ask for advice.

Notes

Likely organisms: E.coli, Klebsiella, other Enterobacteriaceae, less commonly Enterococci, Pseudomonas spp.